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Preparing a dialysis patient for access placement is a process that should ideally begin well before the need for access use. Unfortunately, this is often not the case and patients are often seen well after dialysis has been initiated with a catheter. The process should include a detail-oriented history and a thorough vascular oriented physical examination. A complete history and physical exam will help tailor access options in individual patients. The KDOQI guideline structures the selection and timing of dialysis access, ensuring each patient's medical circumstances and preferences are taken into account. The preparation of a dialysis patient should also include discussion with the patient in regard to their values and expectations before coming to a life-long plan for the patient. This holistic approach aims to achieve reliable and functioning access while preserving future options and improving patient outcomes. This following review will cover the elements of both as well as adjunctive imaging modalities and their indications to allow for successful access placement., Competing Interests: Declaration of competing interest The authors used no AI or AI assisted technologies in the writing process. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Obesity is a complex and chronic disease that can affect the entire body. The review of systems and physical examination are important components of the evaluation. Laboratory assessment is directed toward known cardiometabolic comorbidities. Regular follow-up visits with repeated review of systems, physical examination, and laboratory testing can facilitate early detection and management of comorbidities of this chronic disease., Competing Interests: Disclosure Drs A.E. Weedn, J. Benard, and S.E. Hampl have no financial conflicts of interest relevant to the article to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Rheumatoid arthritis (RA) is a common autoimmune condition affecting approximately 0.5% to 1% of the global population. A significant percentage of these patients will develop hand deformities and dysfunction. Additionally, the hand is one of the earliest manifestations of the disease. Hand surgeons will often encounter patients with rheumatoid arthritis before the patients have received a diagnosis. Therefore, the hand surgeon must be vigilant recognizing RA's clinical signs and to have a thorough understanding in the initial assessment of these patients., Competing Interests: Disclosure The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: To investigate the effect of transcutaneous electrical nerve stimulation (TENS) in reducing barriers to the implementation of exercise therapy and promoting exercise therapy, focusing on physical activity (PA)., Design: A single-center, participant-blinded, randomized controlled trial with a pre-post design., Setting: Orthopedic clinic at a single institution,., Participants: Participants (N=63, aged ≥50y) who had knee pain for ≥3 months were randomly assigned to the TENS (N=21), exercise (N=23), or combined (N=19) groups., Interventions: Participants were provided with 4 weeks of intervention: the TENS group using a wearable TENS device, exercise group performing designated exercises, and combined group performing activities from the TENS and exercise groups., Main Outcome Measures: The primary outcome measure was PA. The secondary outcome measures were 6-minute walk test (6MWT); timed Up and Go (TUG) test; stair climbing; knee pain using the visual analog scale at 6MWT, TUG test, and stair climbing; and patient-reported changes in knee pain over time., Results: At pre- and postintervention, light-intensity PA time (minutes per day) in the TENS, exercise, and combined groups was 735.62±68.82 vs 714.21±73.06 (P=.061), 733.05±103.90 vs 700.31±90.33 (P=.057), and 710.09±62.98 vs 685.22±58.35 (P=.049), respectively, with a significant decrease in the combined group. Significant improvement in knee pain and stair climbing was observed in all groups pre- and postintervention., Conclusions: The group using TENS showed improved effects of early reduction in knee pain and when combined with exercise therapy, a reduction in time spent in light-intensity activities such as sedentary behavior. Thus, the use of TENS in combination with conventional exercise therapy has the potential to reduce psychological barriers to the introduction of exercise therapy. It also promotes and ensures the safe implementation and continuation of exercise therapy., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Child physical abuse is a common cause of pediatric morbidity and mortality. Up to half of all children presenting with abusive injuries have a history of a prior suspicious injury, suggesting a pattern of repeated physical abuse. Medical providers are responsible for identifying children with suspicious injuries, completing mandated reporting to child protective services for investigation, and screening for occult injuries and underlying medical conditions that can predispose to injuries. Early identification of inflicted injuries appropriate evaluations may serve as an opportunity for life-saving intervention and prevent further escalation of abuse. However, identification of abuse can be challenging. This article will review both physical exam findings and injuries that suggest abuse as well as the evaluation and management of physical abuse., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Adult patients with eosinophilic esophagitis (EoE) typically present with a history of dysphagia for solids, sometimes with additional reflux-like pain and a history of prior food impactions. In contrast to these alarming symptoms, the general appearance and physical examination of adult patients with EoE is in line with apparently healthy individuals. Therefore, the diagnosis is based on a history of solid-food dysphagia and eosinophilic tissue infiltration. Importantly, the increasing prevalence of EoE variants, that is, typical EoE symptoms in the absence of a relevant eosinophilia, and several studies with eosinophil-targeting drugs, call the pathogenic role of eosinophils into question., Competing Interests: Disclosure L. Biedermann has consulting contracts with Abbvie, BMS, MSD, Vifor, Falk, Esocap, Calypso, Ferring, Pfizer, Takeda, Janssen, Sanofi. A. Straumann has consulting contracts with Astra-Zeneca, BMS, Calypso, EsoCap, Falk Pharma, GSK and Sanofi., (Copyright © 2023 Elsevier Inc. All rights reserved.)

breeding soundness for several reasons and at several times during their life span. These include before sale for the reason of affirming their sale ability or before a breeding season to determine their readiness for breeding. Bulls may also be evaluated for diagnostic purposes. The breeding soundness examination (BSE) is universally promoted as an important management tool, but there continues to be a level of inconsistency in its performance. A complete bull BSE consists of a thorough physical examination including internal and external reproductive tract, measurement of the circumference of the scrotum and evaluation of individual sperm motility and morphology., (Copyright © 2023. Published by Elsevier Inc.)

Each year millions of children and adolescents undergo sports preparticipation evaluations (PPEs) before participating in organized sports. A primary aim of the PPE is to screen for risk factors associated with sudden cardiac death. This article is designed to summarize the current thoughts on the PPE with a specific slant toward the pediatric and early adolescent evaluation and how these evaluations may differ from those in adults., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: To identify the trends of wheelchair use and physical characteristics among older people who used wheelchairs relative to those who did not., Design: Cohort and survey., Setting: General community., Participants: 7026 participants (N=7026) were selected from the 2011 cohort of the National Health and Aging Trends Study (NHATS), which is made up of Medicare beneficiaries over the age of 65. Repeated observations among participants in the 2011 cohort were analyzed in the 4 following rounds: 2013 (N=4454), 2015 (N=3327), 2017 (N=2623), and 2019 (N=2091). Participants were divided into 2 groups: those who used and did not use wheelchairs., Interventions: Not applicable., Main Outcomes Measures: Physical characteristics, including pain, strength limitation, balance problems, mobility disability, as well as the frequency of going outside., Results: The number of older adults who use wheelchairs had increased significantly from 4.7 per 100 people in 2011 to 7.1 in 2019 (P<.001). The logistic regression analysis indicated that participants who reported less frequently going out were at least 4.27 times more likely to be wheelchair users than non-wheelchair users (P<.01). Participants who reported health and physical problems were at least 2.48 times more likely to be wheelchair users than non-wheelchair users from 2011 to 2017 (P<.0001). Balance or coordination problems increased (24%-38%) significantly among non-wheelchair users from 2011 to 2019 (all P<.05)., Conclusions: Current wheelchair users reported more physical difficulties and were much less likely to go outside. This lower outdoor mobility could be due to physical difficulties or potential barriers in physical and socio-cultural environments. In addition, older adults who do not use wheelchairs showed increasing physical problems over time (including balance or coordination problems). Clinicians should consider older wheelchair users' health and physical limitations when prescribing wheelchairs., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Compression of the neurovascular structures at the level of the scalene triangle and pectoralis minor space is rare, but increasing awareness and understanding is allowing for the treatment of more individuals than in the past. We outlined the recognition, preoperative evaluation, and treatment of patients with neurogenic thoracic outlet syndrome. Recent work has illustrated the role of imaging and centrality of the physical examination on the diagnosis. However, a fuller understanding of the spatial biomechanics of the shoulder, scalene triangle, and pectoralis minor musculotendinous complex has shown that, although physical therapy is a mainstay of treatment, a poor response to physical therapy with a sound diagnosis should not preclude decompression. Modes of failure of surgical decompression stress the importance of full resection of the anterior scalene muscle and all posterior rib impinging elements to minimize the risk of recurrence of symptoms. Neurogenic thoracic outlet syndrome is a rare but critical cause of disability of the upper extremity. Modern understanding of the pathophysiology and evaluation have led to a sounder diagnosis. Although physical therapy is a mainstay, surgical decompression remains the gold standard to preserve and recover function of the upper extremity. Understanding these principles will be central to further developments in the treatment of this patient population., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this article., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Family history and physical exam findings are often the first clues that prompt medical providers to consider clinical genetics evaluation. There is standardized nomenclature for both the pedigree and description of physical features. Systematic evaluation of patients through obtaining family history and careful physical examination is essential to the formulation of a differential diagnosis and plan in the clinical genetics evaluation. The goal of this article is to provide an overview of family history and dysmorphology exam, and their relevance for the clinical genetics evaluation., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Pediatric health care providers caring for patients and families with genetic disease will encounter a range of ethical issues. These include traditional pediatric health care issues, such as surrogate decision making and end-of-life care. Genetic testing raises the importance of informed consent for potential risks that move beyond the oft discussed physical risks and into longer term concepts such as psychological impact, privacy and potential discrimination. Predictive testing in childhood also raises questions of whether the child has an autonomy interest in delaying testing until they have decision making capacity to do so on their own. And finally, treatments including gene therapies and gene editing, may raise issues of identity for families dealing with genetic disease., (Copyright © 2023 Elsevier Inc. All rights reserved.)

This study investigates whether clinical examination is as sensitive as ultrasound and magnetic resonance imaging (MRI) in the diagnosis and localization of symptomatic interdigital neuroma. A retrospective cohort study was conducted at two tertiary centers on all consecutive patients who underwent excision by a single foot and ankle specialist surgeon for a presumed interdigital neuroma between January 2008 and December 2020. Investigators collected preoperative clinical findings, radiological investigations, and postoperative outcomes. Sensitivity and positive predictive values were calculated and Z-score for 2 populations proportions was performed. One hundred fourteen consecutive patients were operated on for 131 suspected interdigital neuroma. Thirteen patients were excluded due to lack of adequate clinical documentation. Of the remaining 101 patients with 118 suspected interdigital neuroma, 115 were confirmed histologically (97.5%). The sensitivity of clinical assessment to accurately diagnose and place an interdigital neuroma in the correct space was calculated as 96.5%. The most common preoperative clinical feature was pain (99.2%). The calculated sensitivity for ultrasound to accurately diagnose an interdigital neuroma was 83.6%, and to correctly locate neuroma was 79.5% respectively, which were both statistically different compared to clinical assessment (p value: <.001 and p value: <.001). The calculated sensitivity for MRI to accurately diagnose an interdigital neuroma was 93.6%, which was statistically different to clinical assessment (p value: .005). Preoperative clinical assessment has the highest sensitivity to accurately diagnose interdigital neuroma when compared to MRI and ultrasound. Preoperative clinical assessment has higher sensitivity to accurately locate interdigital neuroma when compared to ultrasound., (Copyright © 2023 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

"Cup-shaped power reamers" and "flat cuts" (FC) are common joint preparation techniques in first metatarsophalangeal (MTP) joint arthrodesis. However, the third option of an "in situ" (IS) technique has rarely been studied. This study aims to compare the clinical, radiographic, and patient-reported outcomes (PROMs) of the IS technique for various MTP pathologies with other MTP joint preparation techniques. A single-center retrospective review was performed for patients who underwent primary MTP joint arthrodesis between 2015 and 2019. In total, 388 cases were included in the study. We found higher nonunion rates in the IS group (11.1% vs 4.6%, p = .016). However, the revision rates were similar between the groups (7.1% vs 6.5%, p = .809). Multivariate analysis revealed that diabetes mellitus was associated with significantly higher overall complication rates (p < .001). The FC technique was associated with transfer metatarsalgia (p = .015) and a more first ray shortening (p < .001). Visual analog scale, PROMIS-10 physical, and PROMIS-CAT physical scores significantly improved in IS and FC groups (p < .001, p = .002, p = .001, respectively). The improvement was comparable between the joint preparation techniques (p = .806). In conclusion, the IS joint preparation technique is simple and effective for first MTP joint arthrodesis. In our series, the IS technique had a higher radiographic nonunion rate that did not correlate with a higher revision rate, and otherwise similar complication profile to the FC technique while providing similar PROMs. The IS technique resulted in significantly less first ray shortening when compared to the FC technique., (Copyright © 2023 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: To identify the extent and quality of fine motor skill alteration in patients with Dupuytren disease (DD) using an instrumented device measuring grip forces, beyond the commonly used measurement of contracture., Design: Case-control study., Setting: University outpatient clinic., Participants: Patients with DD (N=27) and a contracture >45° (Tubiana stage II, III, and IV) were included and compared with age-matched healthy control patients (N=27)., Interventions: Not applicable., Main Outcome Measures(s): All individuals were subjected to a set of specific tests using a new instrumented device ("manipulandum"). These included lifting, grasping, and then holding the "manipulandum" with 4 different object characteristics (light and heavy weight, rough and smooth surface) along with a measurement of the precision grip strength. Standard measurements including the Nine-Hole Peg Test, a two-point discrimination, and the Disability of Arm, Shoulder and Hand score were evaluated in comparison., Results: Although the measurements of precision grip, two-point discrimination, Nine-Hole Peg Test, and Disability of Arm, Shoulder and Hand score showed no statistically significant differences between both groups, patients with DD applied significantly greater forces when tested with the different subtests using the "manipulandum." Analysis of the 2-phase movement (lifting and holding the "manipulandum") revealed highly significant differences between the groups., Conclusions: Patients with DD use excessive grip forces when lifting and holding the "manipulandum" when compared with healthy control patients, independent of the degree of contracture. As no differences in precision grip strength were seen, the presented approach is useful to obtain additional important information about fine motor function in diseased hands., (Copyright © 2023 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Spasticity results from an abnormality of the central nervous system and is characterized by a velocity-dependent increase in muscle tone or stiffness. In children, it can cause functional impairments, delays in achieving developmental or motor milestones, participation restrictions, discomfort, and musculoskeletal differences. Unique to children is the ongoing process of a maturing central nervous system and body, which can create the appearance of worsening or changing spasticity. Treatment options include physical interventions such as stretching, serial casting, and bracing; oral and injectable medications; and neurosurgical procedures such as selective dorsal rhizotomy and intrathecal baclofen pump., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Lateral ankle ligament sprains and syndesmotic injuries are two different entities. However, they may be combined under the same spectrum depending on the arch of violence during the injury. Currently, the clinical examination has a limited value in the differential diagnosis between an acute anterior talofibular ligament rupture and a syndesmotic high ankle sprain. However, its use is indispensable for raising a high index of suspicion for detecting these injuries. Based on the mechanism of injury, clinical examination plays an essential role in guiding further imaging and early diagnosis of low/high ankle instability., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: To determine whether virtual reality-assisted therapy (VRAT) significantly improves the treatment of peripheral or central vestibular disorders when compared with conventional vestibular physical therapy (CVPT) alone. Indicators of vestibular symptoms are used to determine this., Data Sources: Two reviewers independently searched PubMed, EMBASE, ClinicalTrials.gov, Web of Science, and the Cochrane Collaboration database from January 2010 to January 2022 for studies reporting on VRAT in vestibular disorders., Study Selection: Randomized controlled trials (RCTs) were included that mainly focused on the following measures: the Dizziness Handicap Inventory (DHI), Simulator Sickness Questionnaire, visual analog scale, and balance measures such as the Activities-specific Balance Confidence Scale (ABC), timed Up and Go test, sensory organization test, and center of pressure. The primary outcome was assessment of symptomatic changes before and after VRAT., Data Extraction: Two authors independently conducted the literature search and selection. After screening, meta-analysis was performed on the RCTs using RevMan 5.3 software., Data Synthesis: The results showed that VRAT produced significantly greater improvement than CVPT alone in scores of DHI-Total (standardized mean difference [SMD]: -7.09, 95% confidence interval [CI]: [-12.17, -2.00], P=.006), DHI-Functional (SMD=-3.66, 95% CI: [-6.34, -0.98], P=.007), DHI-Physical (SMD=-3.14, 95% CI: [-5.46, -0.83], P=.008), and DHI-Emotional (SMD=-3.10, 95% CI: [-5.13, -1.08], P=.003). ABC scores did not show improvement (SMD: 0.58, 95% CI: [-3.69, 4.85], P=.79). Subgroup analysis showed that DHI-Total between-group differences were insignificant for central vestibular disorders (SMD=-1.47, 95% CI: [-8.71, -5.78], P=.69), although peripheral disorders showed significant improvements (SMD=-9.58, 95% CI: [-13.92, -5.25], P<.0001). However, the included studies showed high heterogeneity (I 2 >75%)., Conclusions: VRAT may offer additional benefits for rehabilitation from vestibular diseases, especially peripheral disorders, when compared with CVPT alone. However, because of high heterogeneity and limited data, additional studies with a larger sample size and more sensitive and specific measurements are required to conclusively determine the evidence-based utility of virtual reality., (Copyright © 2022 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Advanced health assessment (AHA) serves as the foundational course in advanced practice nurse education in which students apply clinical decision-making skills to gather appropriate subjective and objective data and to begin to formulate diagnostic hypotheses. Summative objective structured clinical exams (OSCEs) have been used in AHA courses to evaluate students' clinical competence. After implementing summative OSCEs in AHA, we found that students struggled with evaluations requiring critical thinking skills and subsequently designed a teaching tool to address this gap. An Episodic Tool was created for the six main body systems with a chief complaint and three age and gender combinations. In small groups, students used the tool to identify pertinent history and physical exam components for a specific age and gender. A faculty-facilitated group discussion followed. A pre/post design was used in this quality improvement project to compare OSCE and oral clinical exam (OCE) scores. OCEs were used in 2020 due to COVID-19 limitations. There was a statistically significant increase of 7 % in the mean OCE/OSCE scores after implementation of the tool (p < .001). Qualitative feedback from students and faculty suggested the tool effectively enhanced students' critical thinking and clinical decision-making skills and promoted consistency across course sections., Competing Interests: Declaration of competing interest None., (Copyright © 2022 Elsevier Inc. All rights reserved.)

This study compared differences in (1) task duration; (2) biometric parameters (ie, caloric energy expenditure, heart rate); and (3) subjective measures of mental as well as physical demand of robotic-assisted total hip arthroplasty (THA) and manual THA. A total of 12 THAs were performed on 6 cadaveric specimens by two surgeons using a wearable technology to track biometric parameters and taking a questionnaire to compare the physical and mental demands. The results of our study suggest that as compared with manual techniques, robotic assistance for THA may reduce mental and physical fatigue., Competing Interests: Disclosure Dr K. Abbruzzese is a Stryker employee. Ms A.L. Valentino is a Stryker employee. Ms L. Scholl is a Stryker employee. Dr E.L. Hampp is a Stryker employee. Dr R. Smith receives research support from Stryker. Dr M.A. Mont is a board or committee member for The Knee Society and The Hip Society, receives research support from National Institutes of Health and is on the editorial board for the Journal of Arthroplasty, Journal of Knee Surgery, Surgical Technology International, and Orthopedics. Dr Mont also receives company support from 3M, Centrexion, Ceras Health, Flexion Therapeutics, Johnson & Johnson, Kolon TissueGene, NXSCI, Pacira, Pfizer-Lily, Skye Biologics, SOLVD Health, Smith & Nephew, Stryker, MirrorAR, Peerwell, US Medical Innovations, and RegenLab. All other authors have no conflict of interest to disclose., (Copyright © 2022 Elsevier Inc. All rights reserved.)

This article describes the extent of the problem and the medical evaluation of child maltreatment, focusing on the outpatient interdisciplinary assessment of suspected child physical and sexual abuse. Separate from their role as clinicians, the roles of the child psychologist before, during, and after the medical assessment are highlighted. The child psychologist is an important member of the interdisciplinary team who helps the team prepare for the evaluation (before), assists in screening and determining immediate psychological safety during the medical evaluation (during), and communicating the need for further treatment and follow-up (after)., Competing Interests: Disclosure The authors have no commercial or financial conflicts of interest to disclose and have received no funding for the creation of this work., (Copyright © 2022 Elsevier Inc. All rights reserved.)

The various mechanisms responsible for the development of metabolic acidosis are briefly reviewed, and the metabolic acidoses are categorized both by mechanism and by the presence or absence of an increased anion gap. When a diagnosis of metabolic acidosis is established, it becomes imperative to identify the primary causative etiology as quickly as possible. This is often readily apparent from the history and physical exam (ie, diabetic ketoacidosis when the glucose is very high in a patient with diabetes mellitus; lactic acidosis in a patient with sepsis and hypotension, etc.). However, when the etiology is not obvious, it is very helpful to determine if the metabolic acidosis is of the hyperchloremic or high-anion-gap type (or a combination of both). Once this categorization has been established, a stepwise consideration of each of the potential causative etiologies will usually direct the clinician to order the appropriate diagnostic studies., (Copyright © 2022 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

This article reviews the key components of a complete history and physical examination for a patient presenting with thumb pain. The history should include the location and severity of pain, alleviating and exacerbating factors, and impact of disability. Physical examination consists of joint palpation; assessment for laxity or stiffness; inspection for swelling, subluxation, or deformity; and provocative maneuvers. Further workup includes plain radiographs with possible dedicated thumb views. Last, we review the Eaton-Littler classification system, a commonly used radiographic grading system, and some of its limitations., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2021 Elsevier Inc. All rights reserved.)

This review focuses on the current applications of telemedicine for drug hypersensitivity reactions. Telemedicine holds promise as a tool to risk-stratify patients with drug hypersensitivity, for both evaluation of penicillin allergies and severe cutaneous adverse reactions. Although telemedicine may not fully replace in-person assessment owing to the need for testing, challenges, and in-person physical examination or skin biopsy, it may allow for risk stratification whereby some in-person visits may not be necessary. Electronic consults have also emerged along with telemedicine as a tool for drug allergy evaluations., Competing Interests: Disclosure D. Wells: No relevant disclosures. K. DeNiro: No relevant disclosures. A. Ramsey: Speakers Bureau for Sanofi/Regeneron and GlaxoSmithKline (not relevant for article)., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Feeding difficulty is common in the pediatric population, particularly in at-risk infants, such as those born prematurely. Appropriate work-up should involve a multidisciplinary team and may commonly use modified barium swallow and flexible endoscopic evaluation of swallow, in addition to history and physical examination. Structural causes of dysphagia may involve surgical management, whereas nonstructural causes may invoke medical therapies. If symptoms do not resolve following intervention, it is important to revisit the interdisciplinary team, because dysphagia is commonly multifactorial in origin. Appropriate identification and early intervention are necessary for successful outcomes in growth and development for children., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2021 Elsevier Inc. All rights reserved.)

This article reviews the pertinent history and physical examination maneuvers necessary to arrive at the proper diagnosis of patients with ulnar-sided wrist pain. Surface anatomy is stressed along with provocative maneuvers for maximal efficacy., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Despite extensive research on ankle instability a consensual and clear objective definition for pathological mechanical lateral ankle instability is yet to be determined. This systematic review aimed to summarize current available arthrometric devices, measuring methods and lateral ankle laxity outcomes in patients with chronic ankle instability that underwent objective arthrometric stress measurement. Sixty-eight studies comprising a total of 3,235 ankles with chronic ankle instability were included. Studies reported a wide range of arthrometric devices, testing position and procedures, and measuring methods. For the anterior drawer test, the average mean differences between injured and uninjured ankles ranged from -0.9 to 4.1 mm, and total translation in the injured ankle from 3.2 to 21.0 mm. Most common pathological threshold was ≥4 mm or ≥10 mm unilaterally and ≥3 mm bilaterally. For the talar tilt test, the average mean differences between injured and uninjured ankles ranged from 0.0° to 8.0°, and total tilt from injured ankle from 3.3 to 60.2°. Most common pathological threshold was ≥ 10° unilaterally and ≥ 6° mm bilaterally. It was found high heterogeneity in the scientific literature regarding the arthrometric devices, use of concomitant imaging and measuring methods of arthrometer-assisted anterior drawer and talar tilt tests which led to variable laxity outcomes in individuals with chronic ankle instability. Future studies should focus on standardizing the testing and measuring methods for an objective definition of mechanical ankle instability., (Copyright © 2021 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

The traditional approach to congenital talipes equinovarus (CTEV) has relied on stepwise manipulations, followed by surgery in severe or recurrent cases. The 3 aims of this study were: (1) to report long-term results of clubfoot treated by posterior capsulectomy and selective release (PCSR); (2) to determine the reliability of a visual scale in the assessment of intraoperative tibiotalar incongruency (TTI); and, (3) to assess the role of TTI as a prognostic factor. We reviewed data regarding 95 CTEV (65 patients) treated by PCSR at a minimum follow-up of 20 years. Patients underwent a physical and radiographic examination, and were assessed through multiple clinical scores. The inter- and intraobserver reliability for TTI evaluation was calculated on clinical photographs. Based on TTI, 52 CTEV were divided in 2 groups (30 congruent vs 22 incongruent) and compared. At a mean follow-up of 26.8 (from 24 to 31) years, 52 CTEV (38 patients) were available for the analysis. Functional results were globally satisfactory. The inter- (κ = 0.748) and intraobserver analysis (κ = 0.688) for the TTI visual assessment showed substantial agreement. In patients with incongruency, patient reported outcomes were significantly worse, with also a greater development of subtalar (p = .02), talonavicular and calcaneocuboid arthritis (p < .001 for both). In treating severe CTEV, the surgical PCSR performed in the first year of life obtains satisfactory clinical and patient-recorded outcomes at over 25 years of follow-up. The visual assessment of TTI is reproducible and potentially represents a long-term prognostic factor., (Copyright © 2020 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Purpose: Children should attend well child visits (WCVs) during early childhood so that developmental disorders may be identified as early as possible, so treatment can begin. The aim of this research was to determine if rurality impacts access to WCV during early childhood, and if altering rurality measurement methods impacts outcomes., Design and Methods: We utilized a longitudinal correlational design with early childhood data gathered from the Virginia All Payer Claims Database, which contains claims data from Medicaid and the majority of Virginia commercial insurance payers (n = 6349). WCV attendance was evaluated against three rurality metrics: a traditional metric using Rural-Urban Commuting Area codes, a developed land variable, and a distance to care variable, at a zip code level., Results: Two of the rurality methods revealed that rural children attend fewer WCVs than their urban counterparts, (67% vs. 50% respectively, using a traditional metric; and a 0.035 increase in WCV attendance for every percent increase in developed land). Differences were attenuated by insurance payer; children with Medicaid attend fewer WCVs than those with private insurance., Conclusions: Young children in rural Virginia attend fewer WCVs than their non-rural counterparts, placing them at higher risk for missing timely developmental disorder screenings. The coronavirus disease pandemic has been associated with an abrupt and significant reduction in vaccination rates, which likely indicates fewer WCVs and concomitant developmental screenings. Pediatric nurses should encourage families of young children to develop a plan for continued WCVs, so that early identification of developmental disorders can be achieved., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Point-of-care ultrasonography (POCUS) is rapidly evolving as a noninvasive adjunct to physical examination among various specialties. POCUS increases the sensitivity of conventional physical examination by providing the answers to simple clinical questions at the bedside. As such, it can reduce fragmentation of care and expedite management. In addition, using bedside ultrasound as the first-line investigation may eliminate unnecessary radiation and contrast exposure. The advent of highly portable and affordable ultrasound devices has made the use of POCUS more practical and user-friendly, making it the stethoscope of the 21st century. This review will provide an overview of the rationale for integrating POCUS into nephrology practice. We also discuss the current scope of POCUS practice and state of training., (Copyright © 2021 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: To verify the suitability and reliability of YouTube videos pertaining to the 5 most commonly used knee stability tests for educational purposes., Design: Cross-sectional observational study., Setting: YouTube videos were categorized into 2 groups according to their sources: professional and nonprofessional groups. Only videos that satisfied the purpose and procedure parts among comprehensiveness scores were defined as suitable for educational purposes. For evaluating the reliability, the modified DISCERN was used. One-way analysis of variance and Kruskal-Wallis test were used to compare continuous and categorical variables, respectively., Participants: Research on YouTube videos (N=218) from November 13, 2019, to November 17, 2019, was done using the following keywords: "anterior drawer test knee," "Lachman test knee," "posterior drawer test," "valgus knee test," and "varus knee test.", Interventions: Not applicable., Main Outcome Measures: Comprehensiveness score that focused on the purpose, procedure, interpretation, and limitations or precautions of the test were developed by the authors, and modified DISCERN score., Results: In terms of the suitability for educational purposes, 126 videos (58%) were classified into the suitable group, and 92 (42%) were classified into the unsuitable group. Neither group had significantly more views, views per posting days, likes, dislikes, or posting days. When comparing the comprehensiveness and reliability scores of each group, significant differences between groups were identified. Only 47 videos met the limitations/precautions category. A total of 155 videos (71%) were from the professional group and 63 videos (29%) were from the nonprofessional group. Significant differences were found in views, views per posting days, likes, and dislikes between the professional group and nonprofessional group., Conclusions: YouTube should not be used for learning about knee stability tests. Professionals, especially those in rehabilitation medicine, should pay more attention to uploading high-quality videos with reliable content., (Copyright © 2020 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Recent advances in ultrasound technology have made ultrasound equipment more versatile, portable, and accessible than ever. Modern handheld, ultra-portable ultrasound devices have been developed by multiple companies and are contributing to make bedside ultrasound evaluation a practice available to all physicians. The significance of making point-of-care ultrasound (POCUS) a common practice that all physicians eventually can use in the evaluation of their patients is changing the way medicine is practiced, allowing physicians to quickly obtain valuable information to complement the traditional physical examination. Despite the proven benefits of using bedside ultrasound imaging as a part of the patient evaluation and for procedure guidance, adoption of this technology still is not widespread among anesthesiology clinicians nor is there uniform teaching of ultrasound skills to anesthesia residents and faculty. Among obstacles that have been identified as precluding achievement of the goal of widespread utilization of POCUS among anesthesia professionals and trainees, are the availability of equipment for all physicians when it is needed and lack of instructor supervision for trainees who desire to use ultrasound but do not always have an instructor knowledgeable in POCUS with them when an ultrasound examination is warranted. Herein, the characteristics, advantages, and limitations of available ultra-portable, handheld ultrasound devices are analyzed, with a focus on the Butterfly iQ (Butterfly Network, Inc, Guilford, CT) pocket probe, which is available at the authors' institution, and how some of its features, such as the capacity to emulate multiple transducers and its cloud-sharing and teleguidance technology, may contribute to increase the availability and use of POCUS by anesthesia clinicians., (Copyright © 2020 Elsevier Inc. All rights reserved.)

The distal radioulnar joint is inherently unstable, relying primarily on ligaments for stability. Disruption of the joint-stabilizing structures can occur in isolation or concomitantly with osseous trauma. Instability can result from dislocations, fractures, ligament injuries, or malunions. Untreated instability alters wrist and forearm kinematics, leading to pain, weakness, and possibly arthritis. In chronic instability, the native ligaments may not be reparable, necessitating a reconstructive procedure., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Distal radius fractures with severe displacement or concomitant triangular fibrocartilage complex tears may be accompanied by distal radioulnar joint instability. Clinicians should examine the distal radioulnar joint closely when managing wrist fractures and treat coexisting instability appropriately. Chronic instability from distal radius malunion may require osteotomy or radioulnar ligament reconstruction. With proper management, most patients recover forearm stability and rotational motion after distal radius fracture., Competing Interests: Disclosure Dr P.R. Ross has received travel, education, and food from Skeletal Dynamics, Synthes, and Zimmer. Dr K.C. Chung has nothing to disclose., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Pyogenic flexor tenosynovitis is a closed-space infection that can lead to a devastating loss of finger and hand function. It can spread rapidly into the palm, distal forearm, other digits, and nearby joints. Healthy individuals may present with no signs of systemic illness and often deny any penetrating trauma or inoculation. Early diagnosis and prompt treatment are required to preserve the digit and prevent morbidity and loss of hand function. Many treatment options have been described, although all share 2 common principles: evacuation of the infection and tailored postoperative antibiotic treatment with close monitoring to ensure clinical improvement., Competing Interests: Disclosure Kanu Goyal receives or has recently received research support from Acumed and Skeletal Dynamics., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Necrotizing soft tissue infections of the upper extremity have varying microbiologies and etiologies. Risk factors for development include diabetes mellitus, intravenous drug use, peripheral arterial disease, smoking, alcohol abuse, and immunocompromised state. Although clinical examination is the mainstay of diagnosis, laboratory tests and imaging can aid in diagnosis. Surgical débridements usually are needed for treatment, with resultant defects that often require reconstruction. Rates of amputation are reported as 22% to 37.5% and mortality from necrotizing soft tissue infections of the upper extremity from 22% to 34%. Prompt surgical and antimicrobial treatment is necessary to decrease risk of loss of limb or life., Competing Interests: Disclosure There are no commercial or financial conflicts of interest from any of the authors., (Copyright © 2020 Elsevier Inc. All rights reserved.)

The glenohumeral joint is prone to instability. Patients with instability should have a physical examination. Imaging studies can provide additional information. Classification schemes that into account soft tissue pathology, neuromuscular control, bone loss, and activity level. An arthroscopic Bankart repair is the mainstay for unidirectional instability. Bone block procedures are indicated for patients with bone loss or a failed attempt at stabilization surgery. The arthroscopic Latarjet is a promising option for these patients. For patients with multidirectional instability, prolonged rehabilitation is indicated, followed by capsular plication or inferior capsular shift if instability is unresponsive to physical therapy., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2019 Elsevier Inc. All rights reserved.)

This article serves as a guide for the pediatric orthopedic physical examination for newborn, children, and adolescents. The newborn physical examination is very unique and therefore is classified separately from the children and adolescent examination. The following pages should be used as an overview of the pediatric orthopedic physical examination and to provide normal parameters, guide a more focused approach that will improve proper diagnoses, and aid in developing a proper management plan. The art of examining a pediatric patient comes with time, and some helpful hints (look for the ♠) can improve the experience., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Individuals born on the spectrum of genetic abnormalities known as mixed gonadal dysgenesis (MGD) have a wide range of anatomical findings and management can be challenging in the newborn and adolescent. Historically, many individuals with MGD have undergone gonadectomy to avert the risk of gonadal malignancy. However, gonadectomy deprives patients of the benefits of their endogenous hormones, potential fertility, and in the case with MGD, has historically been done prior to addressing gender identity. Some patient advocates have proposed a delayed approach to surgical reconstructions and/or gonadectomy in other differences/disorders of sex development (DSD), particularly in patients with congenital adrenal hyperplasia and androgen insensitivity syndrome. In many areas of the world, there continues to be a shift toward delayed reconstructions and hesitancy regarding irreversible gonadectomy. To date, no clinical management protocol addressing these issues from a patient-centered approach has been described. We review what is known about malignancy risk and propose a management protocol for those with MGD that involves shared decision making regarding the gonads and addresses the long-term challenges with regard to gender and anatomy., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Objectives: Determine whether adults with childhood-onset systemic lupus erythematosus (cSLE) are at increased risk for disease- and steroid-related damage as compared to individuals with adult-onset SLE (aSLE), and whether they continue to accumulate disease damage in adulthood., Methods: Data derive from the 2007-2015 cycles of the Lupus Outcomes Study, a longitudinal cohort of adults with confirmed SLE. The Brief Index of Lupus Damage (BILD), a validated, patient-reported measure, was used to assess SLE-associated damage. Participants with baseline BILD were included (N = 1035). Diagnosis at age < 18 years was defined as cSLE (N = 113). Outcome variables included BILD score at baseline and follow-up, clinically significant change in BILD score over follow-up period, and presence of steroid-related damage (cataracts, osteoporosis-related fracture, avascular necrosis or diabetes mellitus)., Results: Mean time between baseline and follow up BILD assessment was 6.3 ± 1.7 years. In adjusted analyses, participants with cSLE and aSLE had similar levels of disease-related damage, and accumulated damage at similar rates. Participants with cSLE were more likely to report steroid-related damage (OR 1.7, 95% CI 1.1-2.8) in the adjusted analysis as compared to those with aSLE. Likelihood of steroid-related damage increased with disease duration for both groups, but was consistently higher among cSLE participants., Conclusion: In this longitudinal cohort of adults with SLE, participants continued to accumulate damage at similar rates over time, regardless of age at onset or disease duration. Childhood-onset predicted increased risk of steroid-related damage. Aggressive use of steroid-sparing treatment strategies during childhood may be important to prevent steroid-related damage in adulthood., (Copyright © 2019 Elsevier Inc. All rights reserved.)